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CORRESPONDENCE FROM ABROAD A Year in Malawi One nurse’s experience working to improve the country’s limited health care capacity. If you want to go quickly, go alone. If you In July 2013, after three years as a pediatric want to go far, go together. NP in the Boston area, I joined the first cohort of —African proverb 15 nurses and 16 physicians in the Global Health Service Partnership (GHSP)—a program developed eturning to Malawi—the self-proclaimed by Seed Global Health, the Peace Corps, and the “warm heart of Africa”—was something I U.S. President’s Emergency Plan for AIDS Relief R had anticipated doing since I first traveled (PEPFAR)—whose aim is to educate nurses and phy- there in 2008, when I was a student at Rhodes Uni- sicians in Malawi, Tanzania, and Uganda. (Seed versity in South Africa. Malawi is a landlocked coun- Global Health was named in recognition of its com- try in southern Africa, the majority of its eastern mitment to “sowing the seeds of change and culti- border flanking Lake Malawi, a 365-mile-long body vating the next generation of health providers where of water lined with small fishing villages and impres- they are most needed.”7) As volunteers, we helped sive baobab trees. Locals dub it the “lake of stars” strengthen health care systems by teaching practical for the bobbing fishing-boat lanterns that line the skills in both university and hospital settings, along- horizon on most nights. Poor populations in rural side host country faculty. parts of Malawi are juxtaposed with urbane, fashion- Vanessa Kerry, a physician and the founder of forward young professionals in Lilongwe and Blan- Seed Global Health, has often referred to the “mul- tyre, where an emerging elite has become noticeable tiplier effect” of teaching: if one person teaches among the day laborers and hawkers on the city five instructors, and each instructor goes out and streets. teaches 20 students, and each of those students During my brief visit in 2008 I was already taken teaches 20 more students, more lives will be affected with the country’s beauty and the people’s friendli- than if one teacher instructs a limited number of ness. But I was also startled by a noticeable lack of students. health care resources. I felt an urgent calling to re- turn to share the valuable skills I was learning in my WORKING IN MALAWI nursing education, and also to know more about My role was to fill gaps in Malawi’s health care ed- the country’s health care challenges. (See Health Care ucation system, which currently does not have enough in Malawi: A Snapshot.1-6) qualified faculty. I taught philosophy of nursing to first- year students and pediatric nursing to third-year stu- dents, sharing knowledge and skills that the students could then impart to their colleagues. I also taught in the clinical setting and assisted faculty with such projects as the Nurse Education Partnership Initia- tive’s nurse mentorship program—part of PEPFAR— designed to support local faculty in sub-Saharan Africa by mentoring students in the clinical setting.6 Teaching was an exhilarating challenge in Ma- lawi. Not only did I need to understand what infor- mation would be most relevant to my students, I also had to learn the value of humanizing statistics. Child mortality is hard to grasp when presented as 68 deaths per 1,000 live births,2 but when one en- counters these deaths daily, numbers become human beings. I remember, for example, walking into the Three infants wrapped in traditional Malawian chitenges share ICU one morning and finding the bed suddenly empty an incubator in the Mzuzu Central Hospital special care nursery. where a three-year-old child with cerebral malaria had Photos by Brittney J. Sullivan. been lying for a week. This put a heartbreaking face 68 AJN ▼ May 2016 ▼ Vol. 116, No. 5 ajnonline.com By Brittney J. Sullivan, MS, RN, CPNP Lake Malawi. and name to one of the many children who would lectures on health assessment, and taught classes on not celebrate a fifth birthday that year. respiratory and cardiovascular health. I also discussed I lived with another GHSP volunteer in Mzuzu— topics that were not specific to nursing, such as bul- a city in northern Malawi—in a simple, comfortable lying in the workplace, working within interdisci- house on the university campus. We had modern plinary teams, and caring for a dying child. Back in amenities—electricity, hot water, running water— Mzuzu I lectured on conducting community health most of the time, although power outages were routine assessments and developing laboratory skills, helped every other Sunday and occurred at other unpredict- local faculty design mentoring projects, and attended able times. We were within walking distance to the interdepartmental meetings. hospital and the main road, where we could share a The frenzied pace of Zomba—where I scurried taxi to town to do the shopping at the open market. through the crowded hospital with 10 or 12 students, My activities varied a great deal from one day showing them how to change a colostomy bag, ex- to the next. While I taught in Mzuzu, my clinical amine the abdomen of a baby, or hear a heart mur- rotations took place in Zomba in the south. The mur amid the cacophony of the pediatric unit—was journey between Mzuzu and Zomba—about 360 interrupted by periods of endless tedium. It was not miles—could take anywhere from seven hours by unusual to wait an entire day for a student to show private transport to a grueling two-day trek com- up at the hospital for an assessment only to learn she bining rides in taxicabs, buses, and pickup trucks, in- was in another city on a different rotation. Or to lin- terspersed by somewhat treacherous walks through ger for hours in a crowded depot waiting for the bus crowded and often muddy bus depots, a 30-pound to fill to maximum capacity before it could depart. backpack with stethoscope and nursing supplies in Most surprisingly, in the spring, about eight months tow. I traveled between Mzuzu and Zomba two or into the GHSP program, my students were granted three times during each six-week rotation. an unexpected month-long vacation. This meant that At the start of the rotation in Zomba I introduced I, too, had a month of no teaching, no grading, and students to the pediatric unit, gave a few pertinent few projects to keep me busy at the university. [email protected] AJN ▼ May 2016 ▼ Vol. 116, No. 5 69 CORRESPONDENCE FROM ABROAD Many Malawians I met faulted Americans for be- provide basic feeding, bathing, and toileting. Little ing perpetually busy, working too much, and living accountability—individual or collective—existed for as though “time is money.” In Malawi, by contrast, patient care. time is just time. I began to develop an appreciation In addition, the scarcity of both human and mate- for patience and gradually learned to slow down too. rial resources was apparent in the university and hos- I spent many electricity-free weekends enjoying Lake pital settings. While the university had a shortage of Malawi with friends and strangers, trading stories and faculty and basic resources such as printers, paper, gaining a deeper understanding of different cultures— and textbooks, the hospital suffered hardships more including my own. Not only had the red African dirt acutely: in one of the tertiary hospitals with a 10-bed permeated my skin, but the people, the work, and burn bay, dressing supplies were always in high de- even the pace had become a part of me. mand. Nurses had sterile water to cleanse wounds It was not uncommon to run out of salbutamol for asthma patients or to encounter broken oxygenators or sinks without soap—and, at times, without water—even in the operating theaters. LACK OF ACCOUNTABILITY AND LIMITED RESOURCES and gauze to cover wounds, but very little else: no as- The Malawian health care system is task oriented. At tringents, silver sulfadiazine, or burn bandages—not the hospital in Zomba, one student was in charge of even tape to keep the gauze in place. Despite these admissions, another handed out medications, a third challenges, the nurses—an average of about six for inserted iv lines and administered fluids, a fourth dis- every 122 patients—did what they could, even if that charged patients, and a fifth rounded with the clinical meant simply keeping wounds covered to prevent flies officers. While nurses were tasked with managing the from infecting vulnerable tissue. flow of the unit, patients’ families were expected to On other units, it was not uncommon to run out of salbutamol for asthma patients or to encounter broken oxygenators or sinks without soap—and, at times, without water— even in the operating theaters. Units were often overcrowded, exceeding twice the Health Care in Malawi: A Snapshot occupancy limit. At the height of malaria season in Zomba, we had 271 children in a unit fit for 91. Malawi, a country of about 16 million people, is ranked 170 out of Sometimes three or four children would lie listless 187 countries on the Human Development Index.1 Between 2009 on the same bed while their mothers sat on the damp and 2012, 62% of Malawians were living below the international concrete floors, never fully dry from the incessant rain. poverty line of $1.25 per day.2 The infant mortality rate is 44 per 1,000 live births, and the maternal mortality rate is a staggering THE EMOTIONAL TOLL 510 per 100,000 live births, with a lifetime risk of maternal death Health care workers in resource-limited settings of 1 in 34 pregnancies.2 Life expectancy in Malawi is only 55 years.2 rarely have the luxury to mourn.

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